[ ]Yes,
I/we would like to take advantage of Leyden Credit Union's Check Card. If I/we do not
qualify for a Leyden Credit Union Check Card, then you may consider this as my application
for a Leyden Credit Union ATM Card.

Signatures: By signing below, the
undersigned request(s) the described services and agrees to terms and conditions governing
the services including fees and charges. The undersigned agree(s) that all information is
accurate and authorizes the LEYDEN CREDIT UNION to verify credit and employment history by
any necessary means including preparation of a credit report by a credit reporting agency.